KYC Declaration Form

KYC DECLARATION FORM

This KYC Declaration Form is made as of Effective Date: by and between Client Name: (the "Customer") and Institution Name: whose principal place of business or registered office is Address: .

RECITALS

WHEREAS, the Institution is required by applicable anti-money laundering, counter-terrorist financing, and other financial crime prevention laws and regulations to obtain and verify information concerning the identity of its customers and, where applicable, beneficial owners;

WHEREAS, the Customer intends to establish or maintain an account, relationship or transaction with the Institution and will provide certain identity, ownership, and source-of-funds information to permit the Institution to satisfy its legal and regulatory obligations; and

WHEREAS, the Institution requires the Customer to make certain declarations, authorizations and acknowledgements as a condition to opening or continuing the business relationship.

NOW, THEREFORE, in consideration of the Institution's acceptance of the Customer and the mutual covenants contained herein, the parties agree as follows:

1. DEFINITIONS

1.1. For purposes of this Declaration, the following terms have the meanings set forth below: "Customer" means the party identified above as Client Name; "Institution" means the party identified above as Institution Name; "Beneficial Owner" means any natural person who ultimately owns or controls the Customer or on whose behalf a transaction is conducted, including any individual owning 25% or more of the ownership interests, and any individual who otherwise exercises significant control.

2. CUSTOMER REPRESENTATIONS AND WARRANTIES

2.1. The Customer represents and warrants that all information, documents and statements provided to the Institution in connection with this Declaration are true, complete and not misleading in any material respect and that the Customer will promptly update the Institution in writing of any change thereto.

2.2. The Customer further represents that it is not incorporated or resident in, nor is the beneficial ownership derived from, any jurisdiction subject to comprehensive sanctions or embargoes that would prohibit the Institution from establishing or maintaining a business relationship with the Customer.

3. CUSTOMER IDENTIFICATION INFORMATION

Type:    Number:    Issue date:    Expiry date:

4. ENTITY TYPE AND BENEFICIAL OWNERSHIP

Applicable entity type (check all that apply): Individual Corporation Trust Other

Does any individual own 25% or more of the Customer?   Yes No

5. SOURCE OF FUNDS AND PURPOSE

6. SANCTIONS, PEP AND ADVERSE MEDIA

6.1. The Customer represents that to the best of its knowledge none of the Customer, its directors, officers, partners, or beneficial owners is listed on any sanctions list, is a politically exposed person ("PEP"), or is subject to any governmental prohibition that would prevent the Institution from conducting business with the Customer.

6.2. The Customer will promptly notify the Institution in writing if any such status or event arises during the course of the relationship.

7. AUTHORIZATION TO VERIFY AND RETAIN RECORDS

7.1. The Customer authorizes the Institution and its agents to obtain, verify and retain information about the Customer and beneficial owners from public and private sources, including credit reporting agencies, registries, registrars and other third parties, in order to satisfy the Institution's legal and regulatory obligations.

7.2. The Customer consents to the collection, use, storage and disclosure of personal data to the extent necessary for identity verification, compliance screening, transaction monitoring and reporting to authorities, as required by law. The Customer acknowledges that the Institution may retain copies of identity documents and verification results for the period required by applicable law.

8. REPRESENTATIONS, WARRANTIES AND COVENANTS

8.1. The Customer represents, warrants and covenants that: (a) all information provided is true, complete and current; (b) the Customer will provide, upon request, originals or certified copies of identity and corporate documentation; and (c) the Customer will notify the Institution promptly of any material change to information provided.

9. INDEMNITY AND LIMITATION

9.1. The Customer agrees to indemnify, defend and hold harmless the Institution and its affiliates, officers and employees from and against any losses, liabilities, fines, penalties, claims or expenses (including reasonable legal fees) arising out of or resulting from any breach of the Customer's representations, warranties or obligations under this Declaration, or from reliance by the Institution on information provided by the Customer.

10. TERMINATION

10.1. The Institution may, in its sole discretion, suspend or terminate the business relationship and take such actions as necessary if the Customer fails to provide satisfactory identification or if continuing the relationship would expose the Institution to legal, regulatory or reputational risk.

11. NOTICES

Notices are effective when delivered in writing to the addresses provided above or such other address as a party designates by written notice.

12. AMENDMENT, WAIVER, COUNTERPARTS

12.1. No amendment, modification or waiver of any provision of this Declaration shall be effective unless in writing and signed by both parties. 12.2. No failure or delay by either party in exercising any right will operate as a waiver. 12.3. This Declaration may be executed in counterparts, each of which shall be deemed an original and all of which together constitute one and the same instrument.

13. GOVERNING LAW, ENTIRE AGREEMENT, SEVERABILITY

13.1. Governing Law: This Declaration shall be governed by and construed in accordance with the laws of the jurisdiction of: , without regard to conflict of law rules.

13.2. Entire Agreement: This Declaration constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior statements and agreements with respect to such subject matter.

13.3. Severability: If any provision of this Declaration is held invalid or unenforceable, the remaining provisions shall remain in full force and effect and the invalid provision will be reformed only to the extent necessary to make it enforceable.

CERTIFICATIONS

By signing below the Customer certifies under penalty of perjury that the information provided in this Declaration is true, correct and complete to the best of the Customer's knowledge and authorizes the Institution to verify such information and to take actions necessary to comply with applicable laws.

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